Wounds involving burns, certain types of bites, and intraoral lacerations require special consideration. Previous issues of this publication have already been devoted to the two former topics. (See Emergency Medicine PRACTICE, Thermal Burns: Rapid Assessment And Treatment, September 2000, and Emergency Medicine PRACTICE, Dog, Cat, And Human Bites: Providing Safe And Cost-Effective Treatment In The ED, August 2003, for more information.) The special-case wounds that have not yet been given in-depth coverage are oral lacerations, which do involve specific care techniques and considerations.

Mouth/Oral Wounds

The mouth and associated structures are highly vascular and therefore tend to heal more quickly than other areas of the body. Because of its extensive blood supply, even small tissue avulsions in the mouth tend to survive. Debridement should therefore tend to favor tissue salvage rather than removal in the oral cavity. The basic approach to oral wounds is the same as for all other wounds — a good examination with attention to possible foreign bodies, such as teeth, followed by thorough wound irrigation. There have been no studies that define a “golden period” for closure of intraoral wounds. In a tongue laceration study by Lamell, mean delay from injury to treatment was 4.5 +/- 9.0 hours (see below).

Buccal Mucosa

Lacerations of the buccal mucosa and oral gingiva heal without repair, provided the wounds are not large and gaping. Large wounds (greater than 2 cm) do tend to trap food and should be repaired. Mucosal lacerations that end up between the chewing surfaces of the teeth also require repair. Otherwise, for small lacerations (2 cm or less), closure is not necessary.²⁰⁷ Through-and-through lacerations should have the layers closed from the inside out, with the caveat that irrigation may be repeated after the inner mucosal layer is closed. Anatomic structures of concern in facial buccal lacerations are the parotid gland and Stensen’s duct. To test for ductile integrity, the inside of the buccal mucosa is dried, then the parotid is pressed; saliva will appear at the duct’s opening, if it is intact. A lacerated duct should be referred to an ENT or oral surgeon for repair.²⁰⁸ A laceration over the gland itself (with an intact duct) is repaired by simply closing the skin over the gland.

Tongue Lacerations

The literature is variable on whether tongue lacerations should be closed. Some suggest that all tongue lacerations be repaired to prevent continued bleeding. In other cases the recommendation is to repair only large gaping or flap lacerations. Several textbooks on oral and dental trauma have different recommendations, ranging from suturing almost all wounds,²⁰⁹ to never suturing any, since suturing can lead to invasive closed space infections.²¹⁰ Still others recommend only suturing wounds larger than 2 cm or when bleeding control is at issue.²¹¹ The only consensus is on lacerations that bisect the tongue, in which case all agree that these should be closed to prevent healing that results in a reptilian, “serpent tongue” appearance.^207-209

There are limited studies on tongue lacerations. A pediatric study of 28 patients found no difference in the quality of result or posttrauma morbidity between those lacerations that were sutured and those that were not. There was also no significant relationship found between laceration size or presence of bleeding on initial presentation and outcome.²¹² The children in this study were triaged to see if they met preestablished criteria for suturing (eg, through-and-through wounds, gaping wounds with tongue at rest), so it was not a strictly randomized study. Also, two of the tongues lost their sutures within 48 hours. Nonetheless, despite this study being somewhat limited by lack of randomization, it suggests no improvement in outcome with suturing. See Table 9 for a composite of recommendations.²¹³

Tongue Closure Technique

The first step with a tongue laceration is always anesthesia, which can be administered in a number of ways. For small lacerations, topical/local anesthesia can be achieved by placing gauze soaked in 4% lidocaine on the area for 5 minutes.²¹⁴ Local injection into the area of the laceration can be performed, though this tends to deform the tissues. Regional blocks may also be used and are highly effective. Either an inferior alveolar block or a lingual nerve block can be used. The lingual nerve block is performed by injecting local anesthetic into the base of the tongue posterior and medial to the most distal molar. A 25-gauge needle is inserted to 0.5 cm in children and 1 cm in adults. Inject 0.5-1.0 cc of local anesthetic, and use epinephrine if bleeding is an issue.²¹⁵

Next, irrigate the tongue laceration. As the tongue often remains a moving target even after anesthesia, it can be grasped by placing gauze over the tip and holding it (or, if fully anesthetized, a towel clamp can be placed on the tip). The wound is then closed with an absorbable 4-0 to 5-0 suture. The sutures should pass through at least half the tongue’s thickness, or the sutures can be placed through all 3 tongue layers in one pass (inferior mucosa, musculature, and superior mucosa). Tie the stitches loosely, because the tongue tends to swell to a significant extent; this can be facilitated by placing an instrument between the tongue and suture while tying the knot.²⁰⁷ All sutures should have at least 4 tying throws, as the tongue’s constant movement (more in some patients than in others) may untie knots

Tongue Laceration Aftercare

Edema is common after tongue laceration closure. A single dose of dexamethasone (0.6 mg/kg) has been recommended by one source to help in significant cases of edema. There is no other literature available to support this approach to tongue edema.²¹³ Cold application (eg, ice, popsicles) can also reduce edema. A soft diet and mouth rinses are recommended for several days.²¹³

Lip Lacerations

The lip is an area where one must be very meticulous in closure technique. Misalignment of as little as 1 mm in the lip’s vermillion border is cosmetically obvious.²⁰⁷ The preservation of the anatomic alignment of the vermillion border is thus what guides proper wound care and closure. (See Figure 2.)

Consider regional anesthesia for lacerations that involve the vermillion border; this prevents distortion of the anatomy and facilitates wound margin approximation. An infraorbital block can be used for the maxillary lip, and a mental nerve block can be used for the mandibular lip. Be aware that anesthesia provided by local injection may distort local anatomy. Consequently, local injection is best done with small injection volumes. If local injection is performed, consider first placing a stitch to approximate the vermillion border. It has also been suggested that an alignment mark can be made on the edges of the vermillion border with methylene blue or a marking pen. The available texts and review articles disagree on the use of this technique, some recommending it and some dismissing t. These recommendations are all based on anecdotal experience, and remain of indeterminate value.

After anesthesia the wound can be irrigated and undergo debridement. Debridement should be minimal, as the highly vascular lip can support relatively devascularized flaps. Closely examine the wound for foreign bodies (eg, teeth). If a tooth or part of one is missing, obtain an x-ray prior to closure. A missing piece of lip does not prevent primary closure, but if over 25% of the lip is missing, the recommendation is that the closure be performed by someone with significant expertise in cosmetic repairs.

Where appropriate, the first suture placed to close a lip laceration should meticulously approximate the vermillion border; then suture toward the wound’s apex. Absorbable 4-0 to 5-0 suture is used for the mucosal surface and 5-0 to 6-0 nonabsorbable suture for the dermal surface. Through-and-through lacerations require that the lip’s layers be closed individually: The muscular/fibrous layer is closed first, then the inner mucosa, followed finally by the outer mucosa. Quinn described the option of closing the muscular/fibrous layer and mucosa together as one unit, then closing the dermal surface.²¹⁶ Aftercare for lip lacerations is the same as for tongue lacerations.

Gingival Lacerations/Degloving

Gingival injuries can occur with mandibular or maxillary fractures. The gingiva can also deglove with local trauma Typically, the gingiva can be stretched (with finger pressure) back to its pre-degloving size, even if it appears too small to do so. The tissue is then sutured in place with 4 or 5-0 absorbable (VicrylTM or MaxonTM) or silk sutures. The suture is anchored through the mucosa on the opposite side of the teeth. This is done by passing the suture between the teeth, then through the opposite mucosa, and back out between the teeth. (See Figures 3 and 4.) These sutures, even if absorbable, are typically taken out in a week, due to the location between the teeth.^207,215

Antibiotics for Intraoral Lacerations

In a double-blind, placebo-controlled study, Steele et al showed that prescribing 5 days of penicillin VK significantly reduced the risk of infection in patients with intraoral lacerations. All wounds were full thickness or through-and-through. Penicillin reduced wound infections from 20% in the no prophylaxis group to 6.7% in the prophylaxis group (p = 0.05).²¹⁷ Penicillin should therefore be used for prophylaxis in intraoral wounds. Clindamycin may be substituted in patients allergic to penicillin, although no study has yet been done with clindamycin. The advantage of antibiotics for tongue lacerations is less clear. In the study by Lamell, none of the children were given antibiotics, and no infections occurred in 28 patients. This underpowered study suggests prophylactic antibiotics may not offer an advantage in lacerations of the tongue.²¹²

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